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Based on review of records and interview, the facility failed to ensure the policy for conducting a Root Cause Analysis (RCA) associated with an adverse patient event had been followed for 1 out of 1 RCAs reviewed. Specifically, no identifiable action plan with monitoring associated with the Root Cause Analysis was found.

Findings included:

A review of the Incident Log for December 2020 showed that Patient #2 was listed on the incident log as "fall with injury sent to HLOC (higher level of care) unresponsive RCA completed".

Staff #3 was interviewed on 6-21-2021. Staff #3 stated this was the only RCA for 2021 that had been completed. It had been completed prior to Staff #3's employment with the hospital. Staff #3 stated there were 2 RCAs that were being initiated but were not complete for review of the RCA process. The surveyor requested to review the completed RCA to ensure the process for reviewing adverse patient events had been followed.

Review of the documents provided showed the organization had initiated an RCA per their policy and that it was a Protected Patient Safety Product. Discussion with Staff #1 and Staff #3 confirmed that an identifiable action plan had not been developed. Staff #3 confirmed that the hospital did not have quality monitors in place to address findings from the RCA to ensure that actions taken had corrected identified problems and had achieved sustainability.

Review of Oceans Healthcare policy titled "Sentinel Events", Revised Date: 10/1/2020, Policy Number: LD-18 was reviewed as follows:

"PURPOSE:
To establish a process for the identification, analysis, reporting both internally and externally, and addressing of sentinel events and the monitoring of corrective actions taken to prevent their recurrence.

PURPOSE:
To provide an opportunity for a reduction in risk to individuals served, after a sentinel even a root cause analysis shall be performed. All sentinel events will be reviewed by the organization. Additionally, the effectiveness of the corrective actions are to be monitored.

A sentinel event is a patient safety event (not primarily related to the natural course of an illness or underlying condition of an individual served) that reaches an individual. Sentinel events at this facility include, but are not limited to, the following:

Death
Permanent harm
Severe temporary harm
...
PROCEDURE:
...
5. Once determined that the incident qualifies as a Sentinel Event, a comprehensive systematic analysis will be completed no more than 45 days after the incident, or after the incident was discovered. A Root Cause Analysis (RCA) is the most used form of a comprehensive systematic analysis used to identify the factors that underlie a Sentinel Event. A Root Cause Analysis focuses on systems and processes, not individual performances.
...
7. A Root Cause Analysis shall be conducted on all sentinel events and shall include the following procedures:
...
- An Action Plan (AP) should be developed that can be implemented to reduce risk.
- The AP should identify who is responsible for implementation, when the action will be implemented and strategies for measuring effectiveness and sustainment of the change.
..."

Based on observation, document review, and interview the facility failed to follow their own policy when storing patients home medications.

Findings include:

An observation tour was conducted on 6/21/2021 after 9:00 AM with Staff #2 and Staff #6.

In the Medication Room, an unlocked cabinet was observed. There was a laminated sign that read "No patient belongings only patient home medications" that was taped to the front of the cabinet door. When this sign was removed, a large opening was noted in the cabinet door. This opening had been cut to a rectangular shape in size. Inside the cabinet was medications for Patient #7, #8, #9, #12, and #13. Patient #12 was discharged on 5/10/2021. Patient #13 was discharged on 5/13/2021. Patient #7 had a weekly pill box in the cabinet. There was no home medication list with the weekly pill box. Patient #8 had a personal bag with home medications. There was no list with the home medications. Patient #9 had a bag with home medications. There was no home medication list with the bag. The cabinet was unsecured allowing access from multiple employees.


Staff #6 provided the home medication list for Patient #7 and #9.


A review of the document titled," Home Medication List" for Patient #7 was as follows:

" ...Various pills in container-unable to identify ..." Signed by Staff #6 on 6/14/2021 at 3:50 PM.

Staff #6 could not confirm or deny if any of the medications in the container were a controlled substance. Staff #6 stated, "The home medication Lists are in the patients medical record."



A review of the facility policy titled, "Medication Management" Policy Number MM-04 with a revised date of 3/01/2021 was as follows:

" ...PURPOSE:

To establish protocol for the inpatient program regarding the regulation of medications brought into the facility from a patient's home.

PROCEDURE:
Admit RN:

3. Complete home medication form or the designated home medication listing in the EMR, as applicable. If home medications are controlled substances, the number of controlled pills is counted and witnessed with along with a 2nd witnessed licensed nurse. Both nurses document the count, date/time, and sign the form.

4. If the home medication is a controlled substance, two nurses count and document same and begin a count log. Controlled medications are stored in the locked medication cart or designated cabinet. The key to the designated cart or cabinet is stored in Automated Medication Dispensing System.

5.Non-narcotic medications are bagged in a security bag and copy of the home medication List form is attached to the bag.

6. The home medication is then stored within a locked secure area within the medication room or behind double locks. Reconciles medications with physician/NPP upon admission and whenever receiving home medications for the patient ..."

Staff #2 and Staff #6 confirmed the findings.

Based on observation, document review, and interview the facility failed to follow the facility policy and ensure a Scheduled IV drug was locked within a secure area.


Findings Include:

An observation tour was conducted on 6/21/2021 after 9:00 AM with Staff #2 and Staff #6.


MEDICATION ROOM

A refrigerator used to store medications was observed. Inside the refrigerator was a keyed lockbox storing Lorazepam. The lockbox was found opened and unlocked. Lorazepam is a Schedule IV controlled drug and must be locked within a secured area. (Lorazepam is a Benzodiazepine, a class of medications commonly used for their tranquilizing and anti-anxiety effects and are often prescribed for panic disorder.) There were 3 boxes, each containing 10-1 ml (milliliter) vials containing 2mg of Lorazepam in each vial to be used for intramuscular or intravenous use.


A review of the facility policy titled, "ADU-Controlled Substance" Policy Number PH097 with a review date of January 2021 was as follows:

" ...POLICY:

For refrigerated controlled medications:

Ativan (lorazepam) injections will be stored in a secure and locked storage container with a key stored in the MedDispense. The counts in MedDispense will reflect the aount in the refrigerator. Nursing staff will follow the same procedures when dispensing a controlled medication (with precounts and dispense quantities), After the key is retrieved, it will be returned to the assigned drawer ..."


An interview was conducted with Staff #2 on 6/21/2021 after 9:00 AM. Staff #2 was asked if the medication lock box should be locked. Staff #2 stated, "Yes it should, and I do not know why it is not." Staff #2 was asked how narcotics were stored that did not require refrigeration. Staff #2 replied, "All narcotics are stored within the Pixys (an automated medication dispensing system). The key for the lock box used in the refrigerator, is also stored in the Pixys." Staff #2 was asked to confirm who had access to the Medication Room. Staff #2 stated, "All RN's (Registered Nurse), LVN's (Licensed Vocational Nurse), and MHT's (Mental Health Tech)."


Staff #2 and Staff #12 confirmed that entry into the Medication Room required a code to be entered on the keypad. Inside the medication room all narcotics should be locked in the Pixys or the refrigerator.


Staff #2 and Staff #6 confirmed the findings.

Based on observation, document review, and interview the facility failed to provide a clean and sanitary environment to mitigate the risks of possible hospital acquired infections in 6 (Patient Nourishment Room, Medication Room, Patient Room #4-A/4-B, Soiled Linen Room, Exam Room, and Laundry) of 6 areas observed. The facility also failed to follow their own policy and ensure 2 of 2 washers and dryers for patients laundry was properly cleaned and sanitized between each use.

This deficient practice had the likelihood to cause serious harm and possibly subsequent death to patients by placing them at high risk for contracting an infectious disease or hospital acquired infection.


Findings include:


An observation tour was conducted on 6/21/2021 at 9:15 AM with Staff #2 and Staff #3.


The following was observed:


PATIENT NOURISHMENT ROOM

The inside of the metal sink had a rust color surrounding the drain. A dark colored liquid was left in the sink. Staff #2 could not confirm what the liquid was. On the countertop, the surface was noted to have several small brown colored spots that resembled a dried liquid. On the countertop were two plastic bins that stored patient supplies. One was labeled "spoons" and the other was labeled "condiments". In the bin labeled "spoons" a single serve unopened Ranch Dressing packet was noted. In the blue bin labeled "condiments" an unwrapped black plastic knife was observed. Inside the bin there was dirt and dust.

A black, 3-tiered rolling cart was used for patient beverages. On the top shelf was two large containers with a dispenser on the front of each of the containers. Under each container was a blue colored towel. The blue colored towel under the large gray container was heavily soiled with a brown color and was wet. The second shelf was noted to have a dried liquid on the surface. This surface was sticky when touched by this surveyor. The bottom shelf was noted with dirt and dust.

Inside the freezer the shelf had dirt, dust, and frozen food particles. Inside the refrigerator was a plastic pitcher that was full of a red liquid. The top was covered with a clear plastic wrap. There was no label on the pitcher that identified the contents, the date it was made, or the expiration date. In the door human hair was observed.

Staff #2 and #5 confirmed the findings.

MEDICATION ROOM

Inside the medication room on the wall nearest the door frame, the paint was chipped exposing the sheetrock. The porous surface cannot be sanitized to prevent the spread of infectious diseases. On the cabinet next to the sink was a blue metal bin labeled "Drug Dispose All" Inside the metal bin was a plastic gallon jug labeled "Drug Buster" (a powdered substance used for drug disposal). Inside the bottom of the blue metal bin it was heavily soiled with dirt, dust, and debris. Hanging on the wall was a paper towel dispenser. On the top of the dispenser dirt and dust was observed. The upper cabinets were noted to be unlocked. A laminated sign that read "No patient belongings only patient home medications" was taped to the front of the cabinet door. When this sign was removed, a large opening was noted in the cabinet door. This opening had been cut to a rectangular shape in size. This opening allowed for dirt and dust to enter the cabinet contaminating the patients home medications and supplies stored on the inside.

A review of the documents located within the medication room in a notebook was as follows:


" ...Ensure ONCE a week, EACH week that a medication nurse has:

1. Checked for, and removed, any food, or drinks present in med room.

2. Checked for, and removed, any expired supplies in med room.

3. Stocked any supplies that are low and/or empty.

4. Checked for, and removed, any patient belongings
a. ONLY patient medications are allowed
b. Any other patient belongings must be stored in the patient belongings room and/or safe.

5. Have housekeeping clean the med room.
a. Must be present with the staff member while this is being performed

*Must: date form, check all tasks are completed and sign your initials EACH week!..."



A review of the document titled "MED ROOM WEEKLY CHECKOFF MONTH: June 2021" revealed no one had completed the document.



A review of the facility policy titled: "Sanitation-Environment-Pharmacy" Policy Number PH015 with an effective date January 2014 was as follows:

" ...POLICY:
The pharmacy will maintain a clean and proper working environment as regulated by the Texas State Board of Pharmacy requirements.

PROCEDURE:

2. The pharmacy will be clean and orderly and equipment in good operating condition ..."

An interview was conducted with Staff #2 on 6/21/2021 after 9:00 AM. Staff #2 was asked who was responsible for the cleaning of the Med Room. Staff #2 stated, "Housekeeping is responsible for cleaning the Med Room, and we have to have a Nurse or responsible staff member stay in there while it is being completed."

Staff #2 and #5 confirmed the findings.


PATIENT ROOM 4-A/4-B

An open storage locker with multiple shelves for patient belongings was inside in the room. On one of the shelves, part of the wood was missing exposing a screw. The shelves had dirt, dust, and debris and paint was missing exposing the porous surface beneath. This surface cannot be sanitized to prevent cross contamination between patients. This was a double occupancy room. In the bathroom, around the base of the toilet, there was dark brown dust surrounding the base. The handrail on the wall next to the toilet that was used for assistance by the patients. The handrail was noted to have dirt, dust, and a rust color along the rail in multiple places.


SOILED LINEN ROOM

There was missing and chipped paint on the wall exposing the sheetrock. The tile floor was peeling apart leaving an open area exposing the concrete surface. This surface cannot be sanitized. There was a floor sink used to clean dirty mops and sweepers that was heavily soiled with dirt, dust, and debris.

An interview was conducted with Staff #4 on 6/21/2021 after 9:00 AM. Staff #4 was asked who was responsible and how often was the room cleaned. Staff #4 replied, "The room should be cleaned daily, and all trash removed." Staff #4 was asked when was the last time the room had been cleaned. Staff #4 replied, "I do not know but it does not look like it was recently cleaned."

Staff #4 confirmed the findings.


EXAM ROOM

This room was used for the examination of patients. Inside the drawer was and emergency Ambu Bag (A bag that can be connected to oxygen for mechanical ventilation in the event of respiratory failure). Under the bag there was heavy dirt and dust. Also, in the room were 2 portable vital sign machines. The tops of the monitors were covered with clear bags. At the base of the poles there was heavy dirt and dust noted. Staff #5 confirmed a clear bag over the portable equipment signified it had been cleaned by staff. An Emergency cart was stored and covered in this room. On this cart was an AED (Automated Emergency Defibrillator) and emergency supplies. The cart was soiled with dirt and dust. A portable light in the corner of the room was noted with dirt and dust on the base of the pole. Staff #2 and Staff #5 confirmed all equipment was readily available for patient use.


A review of the policy titled, "Cleaning and Disinfecting Equipment" Policy Number IC-05.01 with a revised date of 11/1/2020 was as follows:

" ...PURPOSE:
To define a process for the cleaning and disinfecting of equipment and environmental surfaces to prevent the spread of infection.

POLICY:

An Environmental Protection Agency (EPA) registered disinfectant will be utilized to disinfect equipment and environmental surfaces. Equipment and supplies listed as single use devices shall not be reprocessed and reused.

2. Portable Electronic Vital Signs Machines, Electronic Thermometers (responsible party: Nursing) All portable electronic vital sign machines and portable electronic thermometers should be wiped with a disinfectant laden cloth when visibly soiled.

6. Medicine Carts/Emergency Carts/Isolation Carts or Toes (responsible party: Nursing) The inside and outside of all carts will be cleaned and wiped wit a disinfectant laden cloth when visible soiled ..."



LAUNDRY ROOM

There were 2 washers and 2 dryers inside the room for staff to use to do patients laundry. Upon entering the laundry room, it was noted there were patient's clothes in the washer and in the dryer. Also, a wet load of a patient's clothes was observed sitting on top of the dryer. An empty dryer was available directly across from this dryer. Inside the washing machine was patient's clothes that had been washed. The bleach dispenser was noted with dirt, dust, and human hair. Next to this washer was a dryer that had patient's clothes inside. On the top of this dryer was wet clothes belonging to a current patient identified by Staff #11. Directly across from the washer and dryer was another washer and dryer that was not in use. The top of the washer was noted with dirt and dust. Inside the washer, the bleach dispenser was noted with dirt and dust. The rim of the washer tub was observed with dirt and dust. Next to the washer was an additional dryer. The lint trap in the dryer had not been cleaned and there was visible red colored lint in the trap.

An interview was conducted with Staff #11 on 6/21/2021 after 10:00 AM. Staff #11 was asked how the washing machine was cleaned between uses. Staff #11 stated, "We use wipes and wipe down the inside and outside of the machine." Staff #11 was asked if a cycle with bleach was ran in between each patient laundry load to disinfect the machine. Staff #11 stated, "We do not have any bleach, we just use the wipes and wipe the machine down." Staff #11 was then asked if there was a log that was used to document the cleaning and the dates and names of patients laundry that was washed. Staff #11 replied, "We used to do that, but we don't have a log anymore. We used to write it down in a notebook." Staff #5 confirmed there used to be a notebook that documented each cycle that was completed in the washing machine and the dryers.


A review of the policy titled, "Environment of Care and Safety" Policy Number EOC-76 with a revised date of 9/1/2019 was as follows:

" ...POLICY:

Laundering of patient's personal clothes will be provided on-site through the use of a Hospital owned washer and dryer.

Patient's Personal Clothes

The following process will be followed when laundering the patient's personal clothes:

Washing machine and dryer:
The lint filter on the dryer will be cleaned with each use by the hospital staff.
The washer will be cleaned between washing each patient's clothes by running an empty cycle using hot water and one cup of bleach.
Housekeeping wipes off each piece of equipment to assure the outside is clean of dirt and lint.
The lid is opened to wipe off any excess dirt and soap ..."


Staff #2, #3, and #5 confirmed the findings.